Pericardite epistenocárdica: ainda existe? / Epistinocardial pericarditis: does it still exist?

INTRODUÇÃO: A pericardite epistenocáridica é caracterizada como processo inflamatório benigno que ocorre de um a três dias após o infarto (IAM). Com o advento do tratamento de reperfusão, houve uma redução significativa da incidência. Relatamos caso de IAM que evoluiu com derrame pericárdico volumoso com repercussões hemodinâmicas. RELATO DE CASO: Homem, 58 anos, admitido com IAM com supradesnivelamento ST (IAMCSST) anterior, de duas horas de evolução e submetido à trombólise com sucesso. Dois dias após, apresentou recorrência de angina e novo IAMCSST anterior. Foi tratado clinicamente e solicitada transferência para hospital terciário para realização de cateterismo dois dias após. Esse revelou lesão grave em artéria descendente anterior e disfunção importante do ventrículo esquerdo (VE). Foi submetido à angioplastia com stent farmacológico com sucesso. Evoluiu estável, em uso de dupla antiagregação plaquetária, entretanto o ecocardiograma revelou derrame pericárdico volumoso (22 mm), com discreto colabamento de átrio direito na diástole, FEVE 30%, aneurisma apical e trombos em VE. Durante internação, apresentou flutter controlado com amiodarona. Foi tratado com altas doses de aspirina (500mg 8/8h) e colchicina (0.5 mg 12/12h) sem redução do derrame. Optou-se pela realização de janela pleuropericárdica, com drenagem de 350 ml de líquido citrino. Paciente recebeu alta após 14 dias, em uso de rivaroxabana e clopidogrel. Em consulta ambulatorial após cinco meses, paciente estava oligossintomático com ecocardiograma revelando ainda disfunção VE (FE=27%), com acinesia apical, sem trombos e ausência de derrame pericárdico. DISCUSSÃO: A pericardite epistenocárdica está geralmente, relacionada a infartos extensos sem tratamento de reperfusão. Há raros relatos de derrames pericárdicos volumosos, com repercussão hemodinâmica e necessidade de drenagem. É preconizado o uso de AAS em doses anti-inflamatórias, associado a colchicina. Nesse caso, essas medidas não foram suficientes. A anticoagulação era necessária devido trombos e flutter, porém com risco de transformação hemorrágica. A literatura mostra que na vigência de derrame pericárdico, a anticoagulação pode ser segura com controle ecocardiográfico frequente. CONCLUSÃO: Apesar de infrequente, pericardite epistenocárdica pode apresentar derrames volumosos, a despeito da terapia de reperfusão. Este caso evoluiu com achados ecocardiográficos raros e de alto risco com sinais incipientes de tamponamento cardíaco. Inicialmente tratado de forma conservadora, sem regressão do derrame, evoluiu com necessidade de abordagem cirúrgica.

Prevenção de nefropatia induzida por contraste após intervenções coronárias percutâneas com uso de contraste isosmolar / Prevention of contrast-induced nephropathy after percutaneous coronary interventions using isosmolar contrast

INTRODUÇÃO: A despeito dos benefícios da angiografia coronária, para fins diagnósticos e/ou terapêuticos, esse método requer a injeção de contraste iodado, o que em alguns pacientes pode induzir a nefropatia induzida por contraste (NIC). METODOLOGIA: Foram avaliadas de maneira consecutiva todas as intervenções coronárias percutâneas (ICP) realizadas em hospital público terciário, entre janeiro e dezembro de 2016, buscando os pacientes de maior risco para NIC. Incluímos aqueles que utilizaram como contraste, o ioxaglato (baixa osmolaridade) ou iodixinol (isosmolar) e excluímos pacientes que utilizaram outros tipos de contraste ou já realizava hemodiálise. Objetivou-se determinar a taxa de NIC, definida como a elevação da creatinina acima de 25% ou aumento de 0,5mg/dL em relação ao valor basal. Secundariamente, avaliou-se também a mortalidade e necessidade de diálise nos primeiros 30 dias após a ICP. RESULTADOS: De um total de 1219 angioplastias, 382 pacientes fora incluídos em nossa análise. Todos os pacientes receberam hidratação padrão (0,5 a 1ml/kg/h de soro fisiológico 0,9%) pré e pós-procedimento. Contraste de baixa osmolaridade foi usado em 280 (73,2%) casos. Oito pacientes foram excluídos da análise, 5 por já realizarem hemodiálise e 3 por não apresentarem dados de creatinina após procedimento...(AU)

Preliminary results of the multicentric, double-blinded,randomised, Vestasync II trial

Aims: Durable polymers in 1st generation DES have been linked to local coronaryinflammation that could ultimately result in life-threatening adverse events.Polymer-free DES systems have been developed as an attractive alternative tominimise these undesired effects. We sought to assess the safety and efficacy ofthe novel VESTAsync™ Eluting Stent (VES) combining a Cro-Co platform with ananothin-microporous hydroxyapatite surface coating impregnated with apolymer-free low-dose of Sirolimus (55μg). In its first-in-man (FIM) assessment, 15patients were enrolled and at the end of 8 months, late loss and% of stentobstruction considerably low (0.36mm and 4.0%, respectively) with this novelDES.Methods and results: The Vestasync II trial is a randomised (2:1), double-blindedmulticenter comparison of the VES to its platform, the Gen X stent, withmicroporous hydroxyapatite surface coating but without sirolimus. Patients wereeligible if they presented single de novo lesions in native coronary arteries with3.0-3.5mm diameter and ≤ 14mm in length. Primary endpoint was 9-month in-stentlate loss and% of stent obstruction. Lifelong AAS and 6-month clopidogrel wereprescribed to all pts. Seventy-five patients were enrolled. Baseline characteristicsincluded mean age of 57 years and 23% of diabetics. RVD and lesion length were2.67±0.4mm and 14.0±2.0mm. Procedure success was obtained in all cases.Three patients (4.2%) presented non-Q wave MI during hospitalisation with noother MACE. After discharge, there were two cases of TLR and no MI, death orstent thrombosis. Complete invasive follow-up was achieved for all patients. QCAand IVUS analysis are being processed by independent corelabs and detailedresults will be available at the meeting.Conclusions: In confirming the enthusiastic results of its FIM evaluation, theVESTAsync™ Sirolimus-Eluting Stent should be next evaluated in a larger trial withmore complex angiographic profile and clinical endpoints.

Sustained suppression of neointimal proliferation by sirolimus-eluting stents: one-year angiographic and intravascular ultrasound follow-up.

BACKGROUND: We have previously reported a virtual absence of neointimal hyperplasia 4 months after implantation of sirolimus-eluting stents. The aim of the present investigation was to determine whether these results are sustained over a period of 1 year. METHODS AND RESULTS: Forty-five patients with de novo coronary disease were successfully treated with the implantation of a single sirolimus-eluting Bx VELOCITY stent in São Paulo, Brazil (n=30, 15 fast release [group I, GI] and 15 slow release [GII]) and Rotterdam, The Netherlands (15 slow release, GIII). Angiographic and volumetric intravascular ultrasound (IVUS) follow-up was obtained at 4 and 12 months (GI and GII) and 6 months (GIII). In-stent minimal lumen diameter and percent diameter stenosis remained essentially unchanged in all groups (at 12 months, GI and GII; at 6 months, GIII). Follow-up in-lesion minimal lumen diameter was 2.28 mm (GIII), 2.32 mm (GI), and 2.48 mm (GII). No patient approached the >/=50% diameter stenosis at 1 year by angiography or IVUS assessment, and no edge restenosis was observed. Neointimal hyperplasia, as detected by IVUS, was virtually absent at 6 months (2+/-5% obstruction volume, GIII) and at 12 months (GI=2+/-5% and GII=2+/-3%). CONCLUSIONS: This study demonstrates a sustained suppression of neointimal proliferation by sirolimus-eluting Bx VELOCITY stents 1 year after implantation.

Percutaneous handling of coronary lesions >20mm through stents. Is there a first choice strategy?

OBJECTIVE - This study compared the early and late results of the use of one single stent with those of the use of multiple stents in patients with lesions longer than 20mm. METHODS - Prospective assessment of patients electively treated with stents, with optimal stent deployment and followed-up for more than 3 months. From February '94 to January '98, 215 patients with lesions >20mm were treated. These patients were divided into 2 groups as follows: Group A - 105 patients (49%) with one stent implanted; Group B - 110 patients (51%) with multiple stents implanted. RESULTS - The mean length of the lesions was 26mm in group A (21-48mm) versus 29mm in group B (21-52mm) (p=0.01). Major complications occurred in one patient (0.9%) in group A (subacute thrombosis, myocardial infarctionand death) and in 2 patients (1.8%) in group B (one emergency surgery and one myocardial infarction) (p=NS). The results of the late follow-up period (>6 months) were similar for both groups (group A = 82% vs group B = 76%; p=NS), and we observed an event-free survical in 89% of the patients in group A and in 91% of the patients in group B (p=NS). Angina (group A = 11% vs group B = 7%) and lesion revascularization (group A = 5% vs group B = 6%; p=NS) also occurred in a similar percentage. No infarction or death was observed in the late follow-up period; restenosis was identified in 33% and 29% of the patients in groups A and B, respectively (p=NS). CONCLUSION - The results obtained using one stent and using multiple stents were similar; the greater cost-effectiveness of one stent implantation, however, seems to make this strategy the first choice.

[Influence of the clinical presentation on immediate and long-term results after rotational atherectomy]. / Influência do quadro clínico nos resultados imediatos e tardios após aterectomia rotacional.

PURPOSE: To analyse the influence of unstable coronary syndromes (UCS) in the early and late prognosis after rotational atherectomy (RA). METHODS: We treated 236 patients with RA between Aug/1992 and May/1996. Patients were divided into two groups: A) stable coronary syndromes 120 (51%) patients; B) UCS: 116 (49%) patients. DEFINITIONS: 1) procedure success (PS)--lesion success in all locations were RA use was attempted, without a major complication; 2) late coronary events (LCE)--angina, MI, additional revascularization or death. RESULTS: There was a significant predominance of age > 70 (A = 14% x B = 24%, p = 0.03) in B and previous MI (A = 32% x B = 11%, p = 0.0001) in A. Other characteristics were similar in both groups, including complex lesions (type B2/C), which were observed in 77% A stenosis and 80% B lesions. PS was 95% in A and 92% in B (p = NS). In-hospital major complications were observed in 2.5% A and 4.3% B patients, (p = NS). One patient died in each group. A and B patients had similar time of follow-up. LCE occurred in 25% A and 39% B patients (p = 0.002). Recurrence of angina (36% x 23%; p = 0.01) and target lesion revascularization (29% x 18%; p = 0.03) were also more frequently required in B cases. CONCLUSION: This study suggests that UCS (group A) does not implicate in worse acute results after RA. However, UCS patients present greater incidence of late coronary events, particularly recurrence of angina and target-lesion revascularization.

[Coronary angioplasty in patients with restenosis. Characterization of clinical and angiographic profiles, hospital clinical course, and implications for the selection of patients]. / Angioplastia coronária em pacientes com lesões reestenóticas. Caracterização do perfil clínico e angiográfico, evolução hospitalar e implicações para seleção de pacientes.

PURPOSE: To define the clinical and angiographic profile of patients undergoing to a 2nd or a 3rd coronary angioplaty (PTCA) for the treatment of restenosis, and assess the safety and efficacy of redilatation. METHODS: Patients submitted to PTCA for a 1st (1stRE) or a 2nd (2ndRE) restenosis, from Jan/1980 through Dec/1993, were retrospectively identified, and compared to those undergoing to PTCA for de novo lesions (DN). RESULTS: A total of 5,736 underwent to dilatation of primary lesions, 610 of a 1stRE, and 64 of a 2ndRE. Patients with restenotic lesions had a higher prevalence of diabetes, smoking, history of prior infarction (1stRE e 2ndRE) and hyperlipidemia (2ndRE) as compared with primary lesions (p < 0.05). Besides patients with a 2ndRE had a higher incidence of left ventricular dysfunction, as compared to those with DN or a 1stRE (31.3% with EF < 45% in group 2ndRE, vs 19.8% and 23.1% in groups 1stRE and DN, respectively, p < 0.05). Primary success, infarct rate and mortality were similar in all groups, but emergency bypass surgery was significantly higher in the DN (2.1% vs 0.8% in 1stRE and 0% in 2ndRE, p < 0.05). CONCLUSION: Restenosis can be effectively treated by redilatation. Patients with clinical and angiographic features predisposing to further recurrence can be better treated with other interventions (i.e., coronary stents, bypass surgery).

[Inefficacy of diltiazem in restenosis prevention after coronary angioplasty]. / Ineficácia do diltiazem na prevenção da reestenose após angioplastia coronária.

PURPOSE: To evaluate the efficacy of diltiazem in preventing restenosis after balloon angioplasty (PTCA). METHODS: Eighty-nine patients who were undergone to successful PTCA, were divided them in 2 groups (G): A) 44 patients (50%) who received diltiazem (180 mg tid) immediately after PTCA and were kept on it for 6 months); B) 45 patients (50%) who received placebo. Fifty two lesions were dilated in GA and 54 in GB. Patients were excluded from analysis for several reasons, including: necessity of diltiazem or others calcium channel blockers use; heart failure, bradicardia, AV block of any degree, PTCA to chronic total occlusion, ostial lesions and AMI less than 30 days prior to PTCA. Patients were randomized to either the active drug or placebo in a double blind fashion. Restenosis was defined as a 50% lesion. Patients underwent late angiography either at 6 months or sooner if clinically indicated. RESULTS: Both G were similar to age > 70 years (A = 7% vs B = 4%-p = NS), sex (A = 13% vs B = 11%-p = NS), stable angina (A = 43% vs B = 51%), unstable angina (A = 57% vs B = 49%-p = NS) and single vessel (A = 91% vs B = 87%-p = NS) or multivessel (A = 9% vs B = 13%-p = NS) PTCA. We studied 39/44 (89%) patients in GA and 43/45 (96%) in GB (p = NS). We observed restenosis in 17/39 (43%) in GA and 16/43 (37%) in GB (p = NS). The restenosis rate per lesion was 39% in GA and 31% in GB (p = NS). CONCLUSION: Diltiazem was ineffective in the prevention of restenosis following PTCA.

[Acute occlusion after coronary angioplasty. Early management and late course]. / Oclusão aguda pós-angioplastia coronária. Manuseio precoce e evolução tardia.

PURPOSE: Assess the efficacy of the different strategies employed in the management of acute closure and verify the late prognosis of patients who develop this complication. METHODS: From january 1987, through December 1990, 2315 consecutive patients underwent percutaneous transluminal coronary angioplasty (PTCA) in our Institution. We analyzed 100 patients who had had acute closure of the dilated vessel determining the total incidence of myocardial infarction and death, the effectiveness of the different treatment strategies and clinical and angiographic predictors of poor in-hospital outcome. Late follow-up was obtained in the hospital survivors. RESULTS: The incidence of acute myocardial infarction in the group of 100 patients was 57%; death occurred in 12% of the patients. Forty-one individuals were referred to emergency bypass surgery, 35 received clinical treatment and 24 underwent redilatation of the vessel. Those managed clinically had a higher incidence of myocardial infarction compared to the ones who underwent either redilatation or surgery (74.3% versus 50% and 48.8%). The in-hospital mortality rate was significantly higher in patients with left ventricular ejection fraction < 45% (44.4%, p < 0.001) and in procedures involving the left anterior descending artery (20%, p < 0.05); patients undergoing repeat dilatation had the lower death rate (4.2% versus 8.6% in the clinical group and 17.1% in the surgical group). Late follow-up was obtained in 65 of 88 hospital survivors (mean follow-up = 17 months). Patients who underwent repeat dilatation were significantly less symptomatic in the follow-up than those who received medical therapy during the acute phase (89% versus 60.9% of patients without symptoms respectively, p < 0.05). Patients who were referred to surgery had also a tendency towards having less symptoms (87.5% of asymptomatic patients in the late follow-up) although the difference was not statistically significant (0.01 > p > 0.05). CONCLUSION: Acute coronary occlusion is a serious complication of angioplasty and is associated with high rates of major complications (myocardial infarction, death). Low left ventricular ejection fraction and PTCA involving the left anterior descending are predictors of higher in-hospital mortality in patients with acute closure. Late outcome is less favourable in patients submitted to clinical treatment in the acute phase.

[Nonsurgical treatment of coronary pulmonary arteriovenous fistula]. / Tratamento não-cirúrgico de fístula artério-venosa coronária pulmonar.

Fifty eight year old man, with dyspnea, fatigue and progressive angina underwent cinecoronarography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to occlude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronarography 6 months later showed the maintainance of the initial results.

[Heparin in coronary angioplasty. Randomized study in cases with low risk of acute occlusion]. / Heparina na angioplastia coronária. Estudo randomizado em casos com baixo risco para lclusão aguda.

PURPOSE: To assess the efficacy of heparin in preventing the abrupt closure after coronary angioplasty in low risk patients for this phenomenon. METHODS: In the last 4 years, 525 patients successfully dilated were randomized to receive intravenous heparin (n = 264) or not (n = 261) after the angioplasty. The excluding criteria were contraindications for heparin and risk for abrupt closure (refractory unstable angina, primary coronary angioplasty in acute myocardial infarction, evidence of intracoronary thrombus, intimal tear after the procedure and cases of chronic total occlusions). Both heparin and non heparin groups were similar in respect to female sex (15% x 17%; p = NS), age over 70 years old (7% x 9%; p = NS), previous myocardial infarction (26% x 24%; p = NS), multi-vessel procedures (4% x 7%; p = NS, stable angina (40% x 46%; p = NS), unstable angina (52% x 48%; p = NS) and angioplasty after thrombolytic therapy (8% x 6%; p = NS). RESULTS: The overall incidence of abrupt closure was 2/525 (0.4%), with one case (0.4%) in each group. The in-hospital mortality was 1/525 (0.2%), which occurred in a non-heparin patient, due to a anterior myocardial infarction. Major complications occurred similarly in heparin and non-heparin groups (0.4%). Bleeding complications were observed more frequently in the heparin group (7% x 2%; p = 0.002). All of them were in the catheterization site and none required blood transfusion. Severe systemic bleeding were not observed. CONCLUSION: In patients regarded as low risk for abrupt closure, the incidence of this complication was really low (0.4%) and heparin probably do not prevent it.

[The usefulness of digital angiography in performing coronary angioplasty. An analysis of 100 cases]. / Utilidade da angiografia digital na realização da angioplastia coronária. Análise de 100 casos.

PURPOSE: To analyse the actual contribution of digital angiography in the angioplasty setting and to assess its utility to optimize angioplasty results. METHODS: One hundred patients with single vessel coronary artery disease, without previous angioplasty or coronary artery bypass graft surgery, who underwent angioplasty from January to December 1990. Views were obtained in standard films and also in digitized angiograms. The latter was acquired before angioplasty in order to precisely quantify the stenosis and also to measure the reference diameter of the artery that was used and to choose the balloon catheter for each case. New acquisitions were done during and after the end of the procedure to confirm the residual stenosis and to measure the final diameter. RESULTS: The mean stenosis pre angioplasty was 78.2%, the mean reference diameter 2.8 mm and the mean diameter at the stenotic site 0.8 mm. The balloon artery relation was 0.9:1. After angioplasty the residual stenosis was 13.6% and the dilated segment had a final diameter of 2.6 mm. There were no complications in any patient. CONCLUSION: Digital angiography is a useful method for laboratories devoted to coronary interventions for it allows confirmation of the severity of the stenosis, optimizes the balloon/artery relation, monitors partial results and measures the residual stenosis as well as the final diameter.

[The use of primary coronary angioplasty in acute myocardial infarction in patients over 70 years of age]. / Emprego da angioplastia coronária primária no infarto agudo do miocárdio em pacientes acima de 70 anos.

PURPOSE: To evaluate the use of primary coronary angioplasty (PTCA) in patients older than 70 years, evolving with acute myocardial infarction, without the previous administration of thrombolytic agents. METHODS: Forty-two patients with acute myocardial infarction (AMI) and more than 70 years of age (m = 76.4y). There were 54.7% men and 43% of them had anterior MI. PTCA was carried out during the first 12 hours of evolution and in the first 3 hours of duration in 47% of them. PTCA was done only to the AMI related artery, which was the left descending artery in 43%, the right coronary artery in 47% and the left circumflex in the remaining patients. Nineteen percent of these patients were in Killip class III e IV. RESULTS: Primary success was achieved in 86%. The in hospital mortality was 14.2%, and it was superior in female gender (26.3%), in Killip class III and IV (37.5%), in those with multivessel coronary disease (16.6%) and in those where primary PTCA failed (33%). There were 9.3% of reinfarction, but no major hemorrhages happened. Late angiography was done in 50% of patients, showing 72% of patency in the AMI related artery, and a significant improval of global ejection fraction and of the wall motion, particularly, in those who maintained arterial patency. CONCLUSION: Primary PTCA, without former use of thrombolytic agents, when applied early in elderly patients evolving with AMI, has a high success rate and low mortality rate in this subset of high risk patients. It also shows no major hemorrhagic complications.

[Coronary angioplasty in a 12-year-old child]. / Angioplastia coronária em uma criança de 12 anos de idade.

Coronary artery disease is seldom reported in patients under 20 years of age. We present here the case of a 12 years old male, with systemic high blood pressure who had 2 episodes of typical chest pain. He underwent a submaximal exercise treadmill test which was negative. He then underwent cinecoronarography that revealed a 78% (measured by the caliper) obstruction in the proximal segment of the circumflex coronary artery with 3 mm of extension. The left coronary artery and the left ventricle were normal. The patient was subjected to a percutaneous transluminal coronary angioplasty, which was successful and left a 12% (measured by caliper) residual stenosis. The late angiographic restudy (5 months after the procedure) showed the maintenance of the immediate success of the procedure.

[Coronary angioplasty in the 8th and 9th decades of life: an effective technique for myocardial revascularization?]. / Angioplastia coronária em longevos na 8a. e 9a. décadas de vida: uma opção eficaz de revascularização?

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty (PTCA), as a revascularization procedure in patients with symptomatic coronary artery disease in the 8th and 9th decades of life. METHODS: Four hundred and fifty-two elderly patients (mean age 74.7 years) underwent balloon dilation, between April 1982 and June 1990, at the Institute "Dante Pazzanese" of Cardiology. There were 70.4% male, 34.9% with high blood pressure, 18.8% smoked and 10.8% with diabetes. Ninety-four patients (20.7%) had previous myocardial infarction and systemic disorders were diagnosed in 14% (renal failure 5.1%, respiratory insufficiency 3.1%, rheumatic and bone disorders 1.1%, malignancy 4.2%, haematologic disorders 0.4%). One hundred and seventy-three (38.3%) had multivessel coronary artery disease whereas 84 (18.5%) had moderate to severe dysfunction of the left ventricle. PTCA was done according to the method described by Grüntzig, with the use of a "over the wire" (LPS, USCI, Mini Profile USCI, ACX ACS) balloon or a "on the wire" (Probe USCI, Axcel ACS) System. RESULTS: Primary success was achieved in 406 (89.5%) patients where PTCA was done to dilate one vessel in 412, two vessels in 38 and three vessels in 2, accomplishing 494 dilated vessels. Major complications occurred in 14 (3.1%) patients, due to occlusion of the treated coronary artery. Emergency by-pass surgery was necessary in 5 (1.1%) patients, while 8 patients involved to acute myocardial infarction (1.8%), and 5 (1.1%) died. At the end of the late follow-up (mean 24.5 months) of 349 elderly patients (86% of the 406 successful dilated) 246 (70.5%) were asymptomatic, chest pain had recurred in 101 (28.9%) and 2 (0.6%) had myocardial infarction. Twenty-eight patients died during the follow-up, 14 of them (4.0%) due to cardiac causes. Late restenosis developed in 66 patients and 22 had progression of coronary atherosclerosis. Forty patients underwent a late PTCA, and 33 others underwent a late bypass surgery. CONCLUSION: PTCA in patients in the 8th and 9th decade of life was a safe and efficient procedure (primary success rate about 90% and major complications of 3.1%). The late evolution showed satisfactory clinical results (70.5% of asymptomatic) low myocardial infarction rate (0.3% per year) and low incidence of cardiac death (2% per year). About 2/3 of the patients were free of any cardiac event (angina, myocardial infarction, by-pass surgery or death) at the end of the follow-up.

[Coronary angioplasty of moderate lesions (50 to 60%)]. / Angioplastia coronária de lesões moderadas (50 A 60%).

PURPOSE: To assess the efficacy of transluminal coronary angioplasty in patients with moderate (50-60%) coronary lesions. PATIENTS AND METHODS: One hundred and thirty nine patients, 108 (78%) male, mean age was 55 years, who underwent coronary angioplasty from August 1983 to January 1989. Clinical findings included stable angina in 91 (65%) and unstable angina in 48 (35%). Single vessel disease was the case for 117 (84%), whereas 22 (16%) had two vessel coronary artery disease. RESULTS: Primary success rate was 130 (94%). All patients with two vessel disease had complete revascularization. In the failure group there were 2 acute myocardial infarction (1.4%), and 4 (2.8%) emergency coronary artery by-pass surgery. There were no in-hospital deaths. Of the 130 patients with success, 119 (92%) had late follow-up (mean time 31 months). At the end of the follow-up period we found 85 (71%) asymptomatic, while 27 (23%) had recurrence of symptoms. There were 2 late cardiovascular deaths. Fifty four patients underwent late angiography and 42 (78%) had maintenance of the result while 12 (22%) had restenosis, with a mean degree more severe than pre-coronary angioplasty. CONCLUSION: Coronary angioplasty of moderate lesions has a high success rate (94%); nevertheless the rate of major complications and restenosis is very similar to that of coronary angioplasty for severe stenosis. Such findings led us to reserve the indication of coronary angioplasty for moderate lesions for patients at higher risk with clear evidence of myocardial ischemia.

[Use of coronary angioplasty in acute myocardial infarction without previous use of thrombolytic agents. Analysis of 201 patients]. / Emprego da angioplastia coronária no infarto agudo do miocárdio sem uso prévio de agentes trombolíticos. Análise de 201 pacientes.

PURPOSE: To evaluate the experience with the use of primary PTCA in the set of acute myocardial infarction (AMI) without the previous administration of thrombolytic agents. PATIENTS AND METHODS: Two hundred and one patients with AMI, aged 35 to 86 years (mean = 57.2). There were 83.5% men. Twenty patients were older than 70 years and 48.2% had an anterior AMI. PTCA was performed early in the AMI, with a delay no longer than 12 hours. In 95%, it was done solely to the infarct related artery. Seventy percent patients were in Killip class I, 21% in class II, and 8% in classes III and IV (more than 50% of this subset of patients were in cardiogenic shock). RESULTS: Primary success was achieved in 84.5%. In hospital mortality was 5.9%, and there were 7% reinfarctions. Among the 84 patients who underwent a late cinecoronariography study, there were 19% restenosis and 8.3% reocclusions. In the long term follow up 75% were asymptomatic. Repeat PTCA was required in 10.2% of the cases, late coronary surgery was performed on 10.8% of the patients, and post-hospital cardiac mortality was 8.8% during an average follow up of 28 months (range 2-72 months). CONCLUSION: Primary PTCA is a effective way of reperfusion in the AMI, with a high primary success, low complications rate and without any major contraindications.

[Acute myocardial infarction in patients under 40 years of age]. / Infarto agudo do miocárdio em pacientes com idade inferior a 40 anos.

PURPOSE: To evaluate the short and long-term prognosis of a group of patients aged 40 and under, who developed an acute myocardial infarction. PATIENTS AND METHODS: In the last 15 years we studied a group of 73 patients aged 40 and under with a confirmed diagnosis of first acute myocardial infarction. Patients with infarctions caused by coronary embolisms or to revascularization procedures were excluded. RESULTS: Ninety percent were male and mean the age was 35. The most frequent risk factors observed were cigarette smoking in 64 (88%), hypertension in 16 (22%), hypercholesterolemia in 12 (16%) and diabetes in 3 (4%). Seven (9%) patients had no risk factors. The myocardial infarction was anterior em 50 (68%) cases and inferior in the remaining 23 (32%). Severe heart failure (Killip III and IV) was present in 3 (4%). Angiographic studies were performed in 63 (86%). Cineangiography showed critical coronary lesions (obstruction greater than 70%) in one vessel in 38 (60%) patients, multivessel disease in 18 (28%) and 7 (12%) had normal coronary vessels. In-hospital mortality was 5% (3 patients died due to severe heart failure and 1 due to cerebro-vascular accident). The 56 survivors were followed-up to 15 years, with overall survival of 74%. Fourty-nine (71%) were asymptomatic and 7 (10%) had recurrent chest pain. There were 7 (10%) late deaths and follow-up was lost in 6 (9%). Reinfarctions were observed in 5 cases (7%). Revascularization procedures were performed in 12 (17%) patients (bypass-graft surgery in 9 and coronary angioplasty in 3). CONCLUSION: Young patients with acute myocardial infarction have a low mortality rate in the early phase and a favorable outcome after the discharge of the hospital.

[Occlusion of secondary branches after angioplasty of the left descending coronary artery]. / Oclusão de ramos secundários após angioplastia da artéria coronária descendente anterior.

PURPOSE: To evaluate the incidence and clinical presentation of the occlusion of such secondary branches in patients with single vessel coronary artery disease in the left anterior descending artery, who underwent a first elective and successful PTCA. MATERIAL AND METHODS: Two hundred and thirteen side branches of 121 patients considered to be at risk. They were divided into group I (GI-85 side branches, 39.9%), if they originated from the atherosclerotic site; and group II (GII-120 side branches, 61.5%), if their origin would be involved during the balloon inflation. In the GI there were 54 septal branches and 31 diagonal branches, and 36& had angiographic evidence of ostium disease. GII was constituted by 77 septal and 51 diagonal branches, and 7.8% of them had evidence of ostium disease. RESULTS: Seven side branches (3.3%) at risk occluded, 4 from GI (4.7%) and 3 (2.3%) from GII. As for the clinical presentation, 57% of them had angina, where as 28.6% showed minor abnormalities in the ECG. No patient elevated its serum CK-MB, and silent occlusion occurred in 43% of them. CONCLUSION: Occlusion of side branches is a low incidence phenomenon, which happens more often in septal branches with ostium disease that originates from the atherosclerotic site; that about half of the patient had silent occlusion (43%) or mild ischemic manifestations.

[Angioplasty of the anterior descending artery with abnormal origin: use of a new low-profile catheter balloon. A case report]. / Angioplastia da artéria descendente anterior de origem anômala: aplicação de novo cateter-balão de baixo perfil. Relato de caso.

It is possible to perform transluminal coronary angioplasty (TCA) in thin vessels presenting severe obstructions. One of the achievements that made such procedure possible is the development of a new generation of balloon catheters. In this case report the TCA was performed in a very thin left anterior descending artery with an anomalous origin, a quite rare situation that represents a major problem to the traditional dilator system. The catheter used was a Probe (USCI), which differs of the traditional balloons in a number of characteristics. The authors consider the procedure in detail pointing out the advantages of using of the new generations and discuss the impact that newer technological developments will have in enlarging the indications for TCA and improving the results.